Narrative, interpretation, mental health and eating disorders: the connections

Many of the gaps in our understanding of health and illness may turn out to be attributable to our ignorance of the role of cultural factors, long treated in medicine as an optional extra to be contemplated only once the biophysical essentials are properly worked out. However, clinicians, researchers and public health bodies (the WHO Health 2020 policy framework, for instance1) have begun to recognise that a multidisciplinary approach which takes cultural factors seriously is needed to tackle major healthcare challenges of the kind presented by mental illness, meaning that the medical humanities ought to be more than a discretionary and often marginalised optional addition to a medical degree.2 And although meaningful interdisciplinarity is easy to advocate and hard to practise, this article will make the case for one place to start, demonstrating what we stand to gain from a thoroughgoing medical humanities exchange between psychiatry, psychology and cognitive literary studies focused on the preventative, therapeutic and antitherapeutic potential of one aspect of everyday cultural engagement: fiction-reading. Despite the apparent specificity of eating disorders and the obvious vastness of interpretation, I will show that understanding interpretation better can help us understand eating disorders, as well as vice versa. An overview of existing evidence, including a major survey recently carried out in partnership with the charity Beat, will set out our current state of knowledge (and ignorance) and the kind of work that needs to be done next.

The most general grounds for bringing mental health and fiction-reading into dialogue with one another are evolutionary. Storytelling is a universal human activity and an activity apparently unique to humans, and arguments are often made for its evolutionary adaptiveness.3 4 One of the reasons humans have told and listened to stories for so much of their evolutionary history may be that stories have helped us survive as a species, and one of the ways they may have done so is by increasing our cognitive fitness,5 6 perhaps by allowing us to safely test out courses of action that would carry real-life risks or by improving social cognition. As with any evolutionary argument, hypotheses are far more easily made than tested, but there is one quality that speaks directly to the cognitive significance of storytelling: the parallelism between the structures of narrative and of experience itself. Experience is intimately bound up with the narrative spin we put on it: whether it’s framing this dinner as either a dreary networking event or a chance to stock up on some postgym protein, or telling the story of one’s life as a journey towards acceptance or a battle against the odds. The narrativisation of experience (whether or not in words, whether or not in words explicitly spoken or written to oneself or others) is typically automatic and immediate,7 8 and the narratives we read thus occupy an important place within the broader narrativisation to which human experience is constantly subject.

Consequently, narratives can be thought of as ‘the phenomenal form in which patients experience ill health’ (p. 49)9—or at least as one such form. And any narrative, whether cognitively self-generated or chanced on in a work of fiction, is at the same time a form and an object of interpretation. (I will return at the end to the question about the fictionality or otherwise of textual narratives.) Thus, taking a medical history is an interpretive act for both parties: narratives are created that interpret the experience of illness and then are in turn interpreted by the medic and the patient. Ill health is a context where the narratives we tell about ourselves, and which others tell about us—from the medical history to the diagnosis, to the retrospective reflection on illness as one of life’s chapters—become particularly fraught with interpretive possibility.9 The case for a ‘health humanities’ that attends to individuals’ interpretive experiences of reality has been strongly made,10 and whatever specific shapes it ends up taking, productive exchange between clinicians and literary scholars will be crucial to working out how to turn the narratives we constantly create, encounter and recreate to therapeutic advantage.

These considerations already give us a broad remit for asking what relevance engagement with written fictional narratives may have to mental illness. Attempting to sketch out the relevance of fiction-reading to mental illness as a generic whole is probably not the best way to begin, however: such endeavours run a constant risk of overgeneralisation and imprecision. A case study approach is more promising, and given the close links between eating disorders and other common conditions such as depression and anxiety disorders, and between written texts and other art forms, the broader principles (though also the limits of transferability) should readily emerge.

To begin with, though, why investigate written texts (novels, stories and poetry) rather than, say, film, theatre or other ways of engaging with narrative? There are good reasons to expect these other art forms also to exert cognitive–emotional–behavioural effects that might be therapeutically relevant.11 12 Written narrative, however, makes an appealing starting point for investigation because it is the purest instantiation of the capacity of language to generate unlimited meanings from the combination and recombination of a relatively small number of arbitrary symbols. Once we move to empirical investigation, this complexity-from-simplicity makes it possible to attribute cause and effect and control for relevant variables on the textual side far more easily than can be done for the infinite variations on embodied human interaction, lighting, audio quality and so on that make up any theatrical or film production.

When it comes to recipients’ responses, too (as opposed to how to acquire knowledge about them), the qualities of written language versus a filmic or theatrical form are also relevant: as a broad generalisation, we might say that the inherent constraints of the medium (a limited number of characters, diacritics and so on, typically printed or displayed on a two-dimensional surface) leaves more to the cognitive activity of the reader than in any other form of narrative art. This more actively participatory role means we can expect greater variation in individuals’ responses to a given narrative, such that we might observe more salient interpretive differences between, for example, those with and without personal experience of an eating disorder. Arguably, if we are seeking the blankest canvas for the manifestation of interpretive activity, creative writing should be our focus: there, after all, rich narrative material revealing interpretive processing may be generated from the sparsest of prompts. However, the clinical practice of expressive writing or poetry therapy often takes the reading of poetry or narrative as its starting point,13 meaning that the reading component requires systematic investigation as the foundation for investigating of the writing. Furthermore, fiction-reading is a far more common everyday activity than creative writing, which gives its study an ecological validity for a far wider population, especially when it comes to questions about inadvertent (or deliberate) harm through text-cued interpretation.

Finally, within the broad set of processes that can be classified as interpretive, there are several at play in the convergence of fiction-reading and mental health that warrant close attention. The first is mental imagery. When vision is merely providing the initial access (via processing of the words on the page or screen) to the perceptual experience of interest (the imaginative response to what is described), imagery can take different forms from the visual perception of real-world objects or events and from pictorial representations of them. In the eating disorder context, these differences may be significant insofar as a linguistic prompt to imagine something food-related or body-related contains more perceptual freedom than the explicit showing of a body on stage or screen. Language can leave more unspecified, and the imagination may do too,14 15 or else may fill in the textual gaps in therapeutically relevant ways. Second, metaphorical associations are readily and explicitly conveyed in language in ways that may support or otherwise intervene in the associative networks that grow up in an eating disorder, for example, in the form of moralising connections between eating and cleanliness.16 Third, shifts of narrative perspective can be enacted in verbal narrative with a degree of subtlety and precision likely to exert significant influences on the recipient’s cognitive–perceptual alignment with one or more (or no) characters, and so affect his or her cognitive–emotional appraisal of all other elements,15 thus providing a metalayer of interpretive guidance to affect readers’ responses along the other two dimensions.

How, then, having sketched out the relevance of specifically written narrative to mental health, can we configure the case for thinking that fiction-reading as an interpretive act might be therapeutically valuable in the context of disordered eating in particular? Like all mental illnesses, eating disorders are in part illnesses of interpretation—of meaning-creation gone wrong. The distortions involved may range from low-level perceptual and motor discrimination17 to high-level conceptual configurations,18 and interpretive prompts like works of fiction may intervene at multiple levels. Eating disorders thus offer a lens through which to study the ways in which interpretive activity can change under conditions of psychopathology, while interpretation can be seen as one of the fundamental dimensions on which the condition of disordered eating—like all other mental health conditions—is manifested.

Considered as manifestations of interpretive disturbance, eating disorders inhabit both ends of the spectrum that extends from a heightened tendency to perceive interpretive salience in the environment (as found in, for example, schizophrenia19) to a reduced perception of such interpretive salience (in, for example, Parkinson’s disease20). In eating disorders, hypersemic and hyposemic states compete. Food-related and body-related stimuli have high attentional capture and can be objects of both preoccupation and avoidance.21 22 Ruminative brooding and belief in the benefits of rumination often coexist with experiential avoidance and an absence of more constructive reflection: control over the abstract idea of hunger, for example, replaces acknowledgement of the embodied experience of hunger.23 Such changes in interpretive activity have been found to help predict the onset and duration of related clinical diagnoses,23 making clear the importance of studying the underlying cognitive processing. The same conclusion has been reached in eating disorder research on context-dependent fluctuations in body image. Deficits in interpretive processing of physical, emotional and social cues, for instance, can result in rapidly fluctuating misperceptions of body size and shape that help entrench the disorder.24

One contributor to the profound interpretive changes that contribute to eating disorders is the sociocultural dimension. Eating disorders are complex biopsychological phenomena, but they are also culturally inflected in a direct and significant sense: right now, in most (post-)industrialised societies, some variation on slimness is what people are typically trained to aspire to, and both the aspiration and the supporting behaviours are culturally reinforced at every turn. Psychological research (both correlational and experimental) on the effects of mass media makes clear that media depictions of the typical ‘thin-ideal’ body are linked to women’s body dissatisfaction, internalisation of the thin ideal, and eating behaviours and beliefs,25 with conventional and social media images playing different roles.26 Not only images, but language too, can serve as a means of both expressing and encouraging psychopathology, notably on proanorexia websites.27 28 Cultural and aesthetic representations of food, eating, exercise and other bodies, and the value judgements that attach to them, are by no means the only eating disorder risk factor.29 30 However, they can spur interpretive processes that act as potent drivers of an emergent psychopathology, and later on, they can create powerful obstacles to recovery. Yet these representations, along with cultural and aesthetic expressions that extend far beyond the realm of food and bodies, also have the potential to offer strong alternatives to narrowly defined notions of beauty, purity, control and self-worth. Moreover, the more restrictive the mass media’s systems of value become, the more important a role there is for cultural artefacts that encourage exploration of alternative ways of thinking and being, for example, through the processes of cognitive defamiliarisation long theorised to be prompted by ‘foregrounded’ features that deviate from the norms of everyday language use.31 32

Finally, eating disorders also epitomise another often-overlooked characteristic of ‘mental’ illness: the profoundly embodied nature of all ‘psychological’ conditions. Eating disorders help reveal the meaninglessness of any hard-and-fast distinction between mental and physical ill health: having an eating disorder is as much about physical malnourishment and disturbed eating and/or exercise habits as it is about imbalanced mood, cognitive anxiety, low self-esteem or a desire for control, since all enter into complex feedback loops with each other from the very beginning.33 34 Calibrating the physical and psychological facets of recovery is challenging, because cognitive problems arising from malnutrition can (especially in anorexia) easily hamper recovery and can therefore also problematically encourage clinicians to make refeeding the sole focus of treatment. However, these profound mind–body interactions also have the advantage that in recovery from an eating disorder, deliberate, often very simple, self-directed changes—eating more, exercising less and so on—can have rapid and significant effects on the eating disorder system.35 This in turn means that anything which affects attitudes and mental states, and thereby intentions and motivations, has a real chance of making an immediate difference. One potential strand of fiction-reading’s therapeutic efficacy may be as a catalyst of changes to attitudes and motivations, potentially through changes to interpretive tendencies that link the immediate embodied context (eg, the need to eat the next meal as planned) to the wider existential context (what eating this meal will mean for my life).

Research in all these areas offers a strong mandate for an interpretation-focused approach to the study and treatment of eating disorders as complex systems in which disturbances to the structures of interpretation play an important role. In what follows, I outline what is known and not known about how disordered eating and interpretation of texts (including fictional texts) interact, and how we might start to reduce the size of the ‘not known’ category. Some of the evidence presented comes from an online survey conducted in collaboration with the UK eating disorders charity Beat, and while the empirical details are reported elsewhere,36 their wider theoretical import is explored here. This article may give the impression of raising far more questions than it answers, or generating problems with no solutions. I make no apologies for this, since it is with carefully articulated questions that every meaningful research programme must begin. This article aspires to the modest first step of assessing the state of our knowledge and articulating what a sensible second step might look like.

Existing empirical evidence for self-help and creative bibliotherapy

New self-report evidence and future directions

Exploratory research has begun to establish an evidence base linking eating disorders and fiction-reading. A recent online survey attracted 885 respondents, with an average age of 28 (range 18–75, SD 10.26), and of whom 847 were female and 773 reported personal experience of one or more eating disorders (most commonly anorexia), whether past or ongoing. The data, presented in full elsewhere,36 suggest that engagement with fiction can play a major role in maintaining, exacerbating, triggering relapse into, or conversely aiding recovery from an eating disorder.

Key findings include the observation that respondents perceive their preferred type of non-eating disorder fiction to have therapeutic potential combined with a lower antitherapeutic potential than that associated with other text types (eg, fiction or memoir/autobiography about eating disorders and also self-help books). When characterising the helpfulness of reading across all genres, respondents reported positive changes in perspective on illness and recovery as a particularly prominent factor. This finding provides some support for the insight-based model of therapeutic change and also suggests a little more differentiation when it comes to the concept of insight, with five dimensions mentioned with similar frequency: ‘informing you about the facts of eating disorders’, ‘letting you see your eating disorder through someone else’s eyes’, ‘putting your eating disorder into perspective as something that other people have too’, ‘giving you an idea of what recovery might feel like’ and ‘motivating you by giving you a sense of what life could like after recovery’. It is also important to note that since overall helpfulness ratings were higher for self-help than for either fiction or memoir about eating disorders, we cannot necessarily conclude that this kind of insight is likely to be reliably generated by reading narratively structured texts about eating disorders.

More detailed analysis of responses on various dimensions key to disordered eating suggested that for the majority of respondents, their preferred genre of fiction has positive effects on mood, while effects on self-esteem were less pervasive but similarly positive. Meanwhile, effects on feelings about one’s body and diet and exercise habits were more neutral. Conversely, fiction about eating disorders (defined as ‘fiction that includes one or more characters who have named eating disorders, and/or strongly exhibit the symptoms of an eating disorder, and/or exhibit any eating-disorder symptoms that are central to the story’) was reported to have far more consistently negative effects on mood, self-esteem and body-directed feelings, for respondents with and without a personal history of disordered eating. (The healthy control group was, however, small (n=112) compared with the group reporting personal experience of an eating disorder.) Those with a past or present eating disorder reported more strongly negative effects than others on feelings about their body and diet and exercise habits.

The salience of the negative response to eating disorder fiction goes against a major plank of creative bibliotherapy theory: that therapeutic effects are dependent on similarity between the reader’s and the fictional character’s situations. These preliminary results suggest the opposite: that reading about someone else who has an eating disorder is more likely to be experienced as harmful than as helpful with respect to mood, self-esteem, body-related feelings and diet and exercise, whereas reading about scenarios that have nothing to do with eating disorders has potential to be therapeutically beneficial for mood and self-esteem. There are many respects in which a relationship of resemblance may be construed between reader and character, including basic demographic variables, physicality, personality, social and professional context and so on. However, these findings imply that if similarity is taken to pertain specifically to the pathological condition in question, its effects may be equivocal at best, and seriously harmful at worst.

More generally, the data suggest that it may be premature to ascribe all therapeutic cognitive progress to a route through perception of similarity with a fictional other, generation of insight into one’s own condition and problem-solving action. The frequency with which non-canonical, non-realist literature (eg, fantasy, science fiction, children’s or young adult literature like Harry Potter) was described as eliciting important effects suggests that assumptions about the need for simplistic forms of textual realism and optimism should be reconsidered. At least for the case of disordered eating, these early observational findings suggest that if insight is generated, the kind which leads to positive, recovery-oriented action is more likely to be obstructed than encouraged by reader-character or real-world–fictional-world similarity when it comes to the illness in question.

This kind of challenge to the received wisdom about aesthetic engagement and mental health makes clear that further exploration of the dynamics and the results of interpretive activity is warranted. Further investigation is called for not least because fiction-reading can so clearly be harmful as well as helpful. A sizeable subset of the survey respondents’ free responses (answers given in response to invitations to provide more detail about their multiple-choice responses) offer detailed reports of the ways in which fiction about eating disorders comes to play a salient antitherapeutic role, with 18 respondents spontaneously reporting that they deliberately seek out such fiction knowing that it will trigger an exacerbation of their disorder, whether by encouraging a competitive attitude towards the character’s illness (wanting to be thinner or more unwell, or to eat less), by serving as an instruction manual for learning new disordered behaviours or by otherwise entrenching them more fully in the mindset and habits of the disorder. The quantitative data outlined earlier support this observation by suggesting that the exacerbation of an existing eating disorder may occur via changes to disordered behaviours and body-directed feelings in particular.

The qualitative responses also indicate the significance of dynamic feedback loops in which fiction-reading provides an additional input into an already destabilised system. The role of fiction-reading can be either therapeutic (typically by introducing stability-enhancing negative feedback into the system) or the opposite (typically by exacerbating self-reinforcing positive feedback). Nineteen types of positive feedback loop involving fiction-reading were identified in 97 responses (11 instances involving some kind of therapeutically beneficial effect, the rest only antitherapeutic effects). Four types of negative feedback loop were identified in 19 responses (all but four instances therapeutically helpful). (For more detail, see ref 81). Without direct prompting, a significant subset of respondents thus indicated that the dynamics of ‘spiralling’ into illness or stalling in recovery, or conversely finding a stable footing and helpful momentum in ongoing recovery, may involve fiction-reading as a significant contributor.

Interpretation is a critical channel via which such feedback is instantiated. The strength of the interpretive dynamics is especially clear in cases where fiction-reading exerts destabilising effects on the mind–body system. In these cases, there are clear indications that the filtering of textual salience can become highly disrupted, with salience being unduly attributed or denied to elements of the textual content or structure. Among the most poignant responses were those that conveyed (directly or indirectly) the extreme selectivity and persistence of textual processing that can be associated with an eating disorder. This ranged from an exclusive focus on food in texts concerned primarily with other things (eg, The Hobbit) to the envy of a protagonist’s death from an eating disorder that lasts for days after reading about it.

The dynamics of these interactions can be illuminated from the perspective of dynamical systems theory and within the framework of cognitive literary studies, asking how the degree and nature of a reader’s immersion or transportation into the world of the text may affect the overall impact of a textual encounter (see analysis of the survey data from this angle in ref 91). Refining Glavin and Montgomery’s suggestion that transportation may help in achieving critical distance from entrenched patterns of stimulus and response,53 it may be fruitful to conceive of reading as a liminal experience incorporating substantive emotional and conceptual engagement with the characters and situations of the text and, at the same time (and perhaps in changing degrees), a meaningful connectedness to one’s own real-world experiences and constraints. It may be a characteristic of fiction-reading in general that the direct response to a fictional character or their situation is in constant interaction with reflection on this response,92 and in a pathological context this interplay may take significant forms: envy of the extent of the character’s disorder, for example, in tension or alternation with the meta-awareness that such envy is a sign that one’s recovery is not complete, or the self-protective reminder that the fiction is only a fiction, or the analytical identification of textual features that help drive the envy—or indeed the comfort to be drawn from aesthetic appreciation itself.93 The tensions or vacillations between the response and the reflection on it may be mediated by narrative perspective, metaphor, textual imagery, cognitive realism and other characteristics that draw more or less attention to themselves as facets of the textual construction (Ch. 4).15

Testimony to direct, pragmatic, often bodily effects of fiction-reading was widespread in the free-response data. Reading a book may be a distraction from the suffering of real life or from the difficulties of eating, needing to eat or having eaten, although it is often prevented from serving this function by other factors that impede reading: for example, anxiety about the necessity to stop exercise to read or the difficulty of sustaining concentration adequate for reading. Fiction-reading also directly affects embodied sensation and action: some of the causal chains reported in the antitherapeutic direction involved reading making readers feel fatter or heavier, subsequently eating less, exercising more, body-checking more, and/or making themselves vomit—and so further exacerbating the cognitive restrictions of the illness, in turn making future physical vulnerability greater and so on. More positively, reading-mediated cause and effect were described as involving, for instance, learning how to listen to or ‘be in, and stay in’ one’s body again, and encountering new and less constrictive possibilities for engaging with the body and food, such as how to experience one’s body as sexual. This is direct opposition to the hyposemic (avoidant) and hypersemic (obsessive) tendencies that are powerful characteristics of the embodied interpretive disturbances of eating disorders.

Linking back to research outlined earlier on interpersonal benefits of reading, another recurring theme was the value of the fictional world as a social world: reading is often perceived as a way to create meaningful connections with other people, to encounter new role models, and simply to feel less alone, with the text or its characters serving some of the functions of real-world friendship for some readers. As explored earlier in the context of the transportation hypothesis, the significance of these interactions is not dependent on any kind of wholly transported illusion that the text is other than a text: characters can be understood to be characters in books and nonetheless perform some of the important roles that physically real people do (see more detail on this testimony in ref 91). And harking back to our questions about identification, reading can also induce profound feelings of loss of self, with the habitual embodied self ceding to a feeling of identity with the book or the fictional world. This may result in the reader identifying with another (textual) person or in temporary freedom from the bodily dissatisfaction which impedes recognition of things in life that matter more. Finally, reading is reported as stimulating the ability to imagine that life could be other than it is—perhaps the single most fundamental prerequisite for changing one’s interpretive paradigm and so initiating recovery from ‘mental’ illness.